Provider Demographics
NPI:1295778389
Name:GORDY-MOODY, JILL SHANNON (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:SHANNON
Last Name:GORDY-MOODY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JILL
Other - Middle Name:SHANNON
Other - Last Name:GORDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:154 DIANA ST
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1401
Mailing Address - Country:US
Mailing Address - Phone:760-889-8933
Mailing Address - Fax:
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0002
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040058641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical